.08 Patient Long-Term Program.

A. The facilityís interdisciplinary team shall develop and maintain an individualized interdisciplinary comprehensive assessment for each patient to ensure that each patient receives the appropriate treatment modality, whether dialysis or transplantation.

B. Patient Comprehensive Assessment. The patientís comprehensive assessment shall be developed by a multidisciplinary team.

C. The health care team described in §B of this regulation shall review, document, and make appropriate revisions to each patient's comprehensive assessment at least every 12 months or more often as indicated by the patient's response to treatment.

D. When a patient is transferred to another kidney dialysis center, the facility shall ensure that a copy of the patient's comprehensive assessment accompanies the patient, or is sent to the new kidney dialysis center within 1 working day after transfer.